If the insurance company fails to inquire about the relevant situation of the insured, the insured shall not have the obligation to inform.

Published:

2021-12-08

[brief case]] Zu took out personal insurance with an insurance company, and later Zu was diagnosed with "right breast cancer" and was rejected from an insurance company, so he filed a lawsuit. An insurance company argued that Zu did not fulfill the obligation of truthful notification when he was insured. He deliberately concealed that he had suffered from diabetes, solid liver nodules, abnormal liver function and other diseases, and confirmed the major diseases listed in the contract during the waiting period. According to the insurance contract, the insurance company has the right not to pay the insurance premium. After review, the "Health Notice" in the "Insurance Contract" signed by an insurance company and Zu did not mention the inquiries about gestational diabetes, solid liver nodules, and abnormal liver function, and an insurance company did not provide evidence to prove it When applying for insurance, he explained to Zu that the "diabetes" included gestational diabetes, and did not ask Zu whether he had abnormal liver function or solid liver nodules. The People's Court held that the insurance company did not provide evidence to prove that it had asked Zu whether he had suffered from gestational diabetes, abnormal liver function, and solid liver nodules when applying for insurance. Therefore, Zu did not ask questions that the insurance company did not ask. There is no obligation to inform, and the insurance company should pay insurance money to Zu. focus of controversy] Whether Zu has fulfilled the obligation of truthful notification at the time of insurance, and whether the insurance company should bear the responsibility of paying the insurance premium. The court of first instance held that] The Court considers that this case is a dispute over a life insurance contract. The insurance contract signed by Zu and an insurance company is the true intention of both parties. The content does not violate the prohibitive provisions of laws and regulations. It is a valid contract. Both parties should strictly perform their respective obligations in accordance with the contract. The focus of the dispute in this case is: whether an insurance company should pay 350000 yuan to Zu. In this dispute, first of all, an insurance company claimed that Zu did not fulfill the obligation to tell the truth. In combination with Zumou's medical history of "liver nodules" and the requirements of "Health Notification", Zumou has truthfully replied. An insurance company did not submit evidence that Zu had diabetes when he was insured. Secondly, an insurance company claims that Zu has developed symptoms related to the major illness agreed upon in the insurance contract during the waiting period of the insurance contract. According to the existing evidence, Zu found a right breast nodule on October 20, 2019, and underwent medical treatment and examination in November 2019, and was finally diagnosed with breast cancer after re-examination and treatment in March 2020. Although the time of Zu's first visit is within the waiting period of the insurance contract, it belongs to normal examination and treatment. The symptoms of the examination result are the same or similar to the early symptoms of breast cancer. Patients with the above symptoms are only likely to be diagnosed with breast cancer and other cancer diseases, but it is not inevitable. It can not be determined that Zu has breast cancer during this period. Zumou was diagnosed with the first illness for more than the waiting period for the insurance contract. The circumstances of this case are in line with the relevant provisions of the major disease insurance in the insurance contract involved in the case. "The insured shall be diagnosed by a Junior College doctor in a medical institution designated or approved by the company for non-accidental reasons within 180 days from the effective date of the contract." One or more major diseases listed "is obviously inconsistent. The relevant defense of an insurance company lacks factual basis and is not supported by this court. Third, an insurance company argued that Zu should report the deterioration of his health to him during the waiting period of the insurance contract in accordance with Article 52 of the the People's Republic of China Insurance Law. This clause is in response to the provisions of the property insurance contract on the "obligation to notify of increased risk", and the insurance contract in question is a life insurance contract. An insurance company invoking this provision to claim exemption is an error in the application of the law, which is not adopted by the Court in accordance with the law. In summary, the Court does not support the relevant defenses of an insurance company. The court of second instance held that] The Court held that the case was a dispute over a life insurance contract. According to Article 323 of the Interpretation of the Supreme People's Court on the Application of the the People's Republic of China Civil Procedure Law, the people's court of second instance shall hear the appeal request of the party concerned. If the party concerned fails to appeal, the case shall not be heard. Combined with the arguments of both parties, the focus of the dispute in the second instance of this case is: whether the 1. Zu has fulfilled the obligation of truthful notification when applying for insurance; whether the 2. Zu has been diagnosed with breast cancer during the waiting period of the insurance contract. With regard to the first focus of the dispute, the question of whether Zu had fulfilled his obligation to tell the truth when he was insured. Article 16, paragraph 1, of the the People's Republic of China Insurance Law stipulates: "If an insurance contract is concluded and the insurer inquires about the subject matter of the insurance or the relevant situation of the insured, the applicant shall truthfully inform it." Paragraph 1 of Article 6 of the Interpretation (II) of the Supreme People's Court on Several Issues Concerning the Application of the the People's Republic of China Insurance Law stipulates: "The obligation of the policyholder to inform is limited to the scope and content of the insurer's inquiry. If the parties dispute the scope and content of the inquiry, the insurer shall bear the burden of proof." According to the provisions of the above-mentioned laws and judicial interpretations, the current law of our country adopts the mode of inquiry and notification, that is, the insurer asks about the subject matter of the insurance or the relevant situation of the insured, and the policyholder truthfully informs the questions asked, and the scope of the policyholder's notification is limited to the questions asked by the insurer. In this case, an insurance company claimed that Zu did not truthfully inform gestational diabetes, abnormal liver function and solid liver nodules at the time of insurance. Therefore, an insurance company should prove that it has asked Zu whether he has or has suffered from the above three diseases at the time of insurance. Only on the premise of an insurance company's inquiry, Zu has the corresponding obligation to inform. About whether gestational diabetes falls within the scope of what should be told truthfully. An insurance company inquires about Zu at the time of insurance through the Health Notice. Among them, the Health Notice asks "Do you have or have suffered from the following diseases or symptoms, or have been examined or treated for the following diseases?... (4) Endocrine or immune system diseases (diabetes mellitus...)". It can be seen that an insurance company only asked whether Zu had or had had diabetes, but did not ask whether Zu had or had had gestational diabetes. An insurance company did not prove that the meaning and type of "diabetes" included gestational diabetes, nor did it prove that the expanded interpretation of "diabetes" included gestational diabetes at the time of the conclusion of the contract. Moreover, in the gestational glucose tolerance test, the index of the 1-hour blood glucose test result in only one prenatal examination slightly exceeded the normal value range, and the 2-hour test result was within the normal value range. The other blood glucose tests conducted by the prenatal examination and the blood glucose test results during the subsequent hospitalization due to illness were all normal. An insurance company had no evidence that Zu had diabetes. Therefore, an insurance company did not ask whether Zu had gestational diabetes when applying for insurance, and Zu did not have the obligation to truthfully inform gestational diabetes. Whether abnormal liver function and liver solid nodules belong to the scope that should be truthfully informed. An insurance company asks through the Health Notice, "Do you have or have ever had the following diseases or symptoms, or have you been examined or treated for the following diseases?... (5) Digestive system diseases (×× virus infection or carrying, liver cirrhosis, severe ××...)". It can be seen that at the time of insurance, an insurance company asked Zu whether he suffered from or had suffered from XXX virus infection or carrying, liver cirrhosis and severe XXX diseases. An insurance company did not ask Zu whether there was any "abnormal liver function" in the examination report, did not explain which liver diseases "abnormal liver function" included, and did not ask Zu whether he had solid liver nodules. Regarding the solid nodules of the liver, Zumou was diagnosed as hepatic hemangioma by examination. Zumou had voluntarily and truthfully informed him that he had suffered from hepatic hemangioma and the diameter of the hemangioma was not more than 5cm. Therefore, because an insurance company did not ask whether Zu had abnormal liver function or solid liver nodules when applying for insurance, Zu did not have the obligation to tell the truth. To sum up, an insurance company did not ask Zu whether he had gestational diabetes or whether he had abnormal liver function or solid liver nodules. Zu did not have the obligation to tell the truth about the questions that the insurance company did not ask. An insurance company claimed that Zu did not fulfill the obligation of truthfully informing when applying for insurance, lacking factual basis and legal basis, and the court did not support it. On the second focus of the dispute, whether Zumou was diagnosed with breast cancer during the waiting period of the insurance contract. The critical illness insurance clause of the insurance contract involved in the case states that the insured shall be diagnosed by a Junior College doctor in a medical institution designated or approved by the company for non-accidental reasons within 180 days from the effective date of the contract. For one or more major diseases, the company shall pay the basic critical illness insurance premium according to the accumulated insurance premium (without interest) paid by the insured in this contract, and this contract shall be terminated at the same time. According to the provisions of the above-mentioned insurance terms, if the insured is diagnosed with a major illness listed in the contract within 180 days of the waiting period, the insurer shall only pay the basic major illness insurance premium in accordance with the amount of the insurance premium paid by the policyholder, and the contract shall be terminated. The first paragraph of Article 64 of the the People's Republic of China Civil Procedure Law stipulates that the parties have the responsibility to provide evidence for their claims. An insurance company claims that Zu was confirmed to have breast cancer within 180 days of the waiting period, and an insurance company bears the burden of proof. The waiting period for the insurance contract involved is 180 days from June 16, 2019 to December 12, 2019. On October 20, 2019, the physical examination showed a right breast nodule. On November 10 and 26, 2019, Zu went to hospital for B- ultrasound examination and was diagnosed as right breast nodule grade BI-RADS3. An insurance company has no proof to prove that the BI-RADS3 level of breast nodules is the standard for the diagnosis of breast cancer. Therefore, the examination conclusion "BI-RADS3 level of right breast nodules" cannot prove that Zu has been diagnosed with breast cancer. An insurance company has no proof that Zu has been diagnosed with breast cancer as of December 12, 2019, and an insurance company claims that Zu was diagnosed with breast cancer during the waiting period, which lacks factual basis. According to the existing evidence, the court of first instance found that Zu had exceeded the waiting period of the insurance contract involved in the case when he was diagnosed with breast cancer. Based on the above analysis, the evidence submitted by an insurance company is not enough to prove that Zu did not fulfill the obligation of truthful notification when applying for insurance, and there is no evidence to prove that Zu was diagnosed with breast cancer during the waiting period. Breast cancer belongs to the scope of claims stipulated in the insurance contract involved in the case, Zu is in the insurance contract waiting for the expiration of the diagnosis of the above-mentioned disease, an insurance company also has no evidence to prove that there is an exemption from insurance liability in this case, so an insurance company should pay Zu a full amount of insurance compensation agreed in the insurance contract. Lawyer Advice] According to the provisions of the Insurance Law and other relevant laws and regulations, the policyholder's obligation to inform is limited to the scope and content of the insurance company's inquiry. For questions that the insurance company has not asked, the policyholder does not have the obligation to inform, and if both parties dispute the scope and content of the inquiry, The insurance company shall bear the burden of proof. Through this case, it is suggested that the insurance company should strictly fulfill the corresponding obligation of inquiry and notification when carrying out insurance business, and make the scope and content of the inquiry as specific and clear as possible to avoid ambiguity.

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